State Form Number (SFN) 17081

Claim for Wages

Preliminary Procedures for Filing a Claim for Wages

Step Three:

If the employer does not respond within the time frame allowed or if the response is insufficient, you may file a
claim for wages with the Department of Labor and Human Rights.

If the employer has not responded to your demand letter (as described in the preliminary procedures) with full
payment, it is your right to file a claim for wages with the Department of Labor and Human Rights by completing the claim for wages form. However,
do not fill out the claim for wages form if:

You acted as an "Independent Contractor" and not as an employee of the business,

You are self-employed,

You intend to bring a private legal action against your employer regarding this claim for wages,

You already have a judgement involving the same claim for wages,

Your employer has filed for bankruptcy. If so, you should contact the Bankruptcy Court or a private attorney for
further instruction. The address of the Bankruptcy Court in North Dakota is 655 1st Ave North, Suite 210 Fargo, ND
58102. The telephone number is (701) 297-7100.

Your claim is for unpaid wages that have been owing for more than two years as there is a two-year statute of
limitations for department investigation.

Instructions for Completing Claim for Wages (SFN 17081)

Read all questions on the claim for wages form carefully before answering. Your claim should be filled out completely and
legibly, and must be signed and dated. Please print or type and do not staple any items to the claim.

Be certain that your name, address, and telephone number are correct. If you do not have a telephone, please try to
provide the number of a friend or relative who could contact you. If your address or telephone number changes after
filing the claim, you must notify the Department of Labor and Human Rights. Your claim may be closed if we are unable to reach you.

Provide your employer's name, name of the business, correct address and telephone number. Provide a dollar
amount due. If you are filing against more than one employer, use a separate claim for wages form for each. Also, each
claimant filing against an employer must use a separate claim form. Return the original, signed and dated form to the
department.

Note of Explanation and Supporting Documentation:

Along with the completed form, it is important that you send any documentation you have to support your claim.
Documentation that may be useful includes:

A signed note explaining the circumstances of the claim, how you arrived at the claim amount, and any other
relevant information

A copy of the demand letter you sent to the employer

A copy of your paycheck (front and back) and check stubs or payroll vouchers

A copy of any agreements that were entered into and signed by the you and the employer

A written, notarized statement, with name and address, from fellow employee(s) who could substantiate the
claim

A copy of your work schedules, time sheets, or any other documentation verifying the number of hours worked

If the claim involves a verbal agreement, provide a thorough written statement detailing the terms of the
agreement

A copy of your W-2 form from the employer

Counter-Claim Process:

North Dakota Century Code §34-14-05 allows the Commissioner of Labor to consider counter claims from employers for
any offsets or deductions to the wages asserted by an employee filing a claim for wages.

Employers are notified of this right and the process to follow to file a counterclaim in the initial claim
notification letter sent to them from the Department of Labor and Human Rights. The department will not accept a counterclaim for issues
of alleged theft or till shortages or for any legal costs or time incurred by an employer in responding to a claim for wages. Please note that an employer may file a counter claim only after a claim for wages has been filed by an
employee.